In this two-part series, we examine the occupational therapist's role in preparing and adapting an upper extremityprosthesis. This month, the authors present preprosthetic assessment and treatment.

Replacing a missing limb is never an easy process. The planning can't be rushed. And each case is different, with its own nuances and set of circumstances.

Obviously, one clinician can't handle it alone. A rehab team comprised of a physician, prosthetist, occupational therapist and case manager must each fill a role if a person with an acquired extremity upper limb loss is going to achieve an optimal outcome.

For the occupational therapist, preprosthetic assessment and treatment is crucial to help people adapt to a new prosthetic device. During this first phase, you should address range of motion, scar management, desensitization/pain issues and independence training to prepare the person to wear a prosthetic device.

A preprosthetic assessment lets you understand a patient's needs by evaluating and documenting the situation. By doing so, you get a complete picture and determine factors that may play a role in future prosthetic use. You should have an idea of family support, social history (including occupation, plans for return to work or school, description of a home environment), hand dominance and medications. Psychosocial factors may come into play, such as patient expectations, coping with the loss of an arm, accepting a new appearance and knowing what's in store with rehabilitation.

First, determine the reason for the referral and type of amputation. Usually this information accompanies a physician's request, and it should include etiology and onset. In addition, take a look at past medical history and rehab needs.

If this isn't a new injury, discuss prior prosthetic devices. It's important to determine the type of past prostheses—body-powered, myoelectric or hybrid—to know whether the device was successfully integrated into the patient's daily life. If the patient received a prosthesis and didn't wear it often, document the reason.

Ask if the patient is a "wearer and user." Some may wear a myoelectric or body-powered prosthesis for cosmetic reasons, but don't use it for daily tasks.

After gathering background information, start documenting objective data. This information helps establish a baseline so you can regularly note changes or progress. Look at the following areas:

-Range of motion. Use a goniometer to measure remaining joints for potential ROM. Document joints that don't fall within normal limits, and focus on improving these areas for optimal prosthetic use.

For a unilateralamputation, document ROM of the sound limb and residuallimb. Sound limb ROM, along with chest expansion and scapular mobility, are important during prosthetic use, especially with a cable-controlled system.

For a bilateral upper extremityamputation, check neck, trunk and lower extremity ROM. Better flexibility allows the patient to use compensatory techniques, such as "body English" for greater functional independence while he waits for a prosthesis. With body English, the client uses his body to move on the object to accomplish a basic task. For instance, a hairbrush can be positioned so a client can move underneath it to comb his hair.

Evaluate both arms to determine weak areas and assess contractions of remaining muscle groups, even if the lever arm or joint is absent. For example, in the case of a unilateraltransradialamputation, have the patient extend the wrist of the sound arm against resistance. Instruct him to remember the "feel" of the contraction with that resistance, and then try to transfer the motion to the residuallimb muscle group.

Describe findings based on a grading system of poor, fair or good. You also can use myotesters to determine strength.

-Shape. Describe the shape of the residuallimb. A conical shape, which is ideal, is tapered with a rounded bottom. A bulbous residuallimb may look like a light bulb, and it's characterized by flabby, hanging skin. A cylindrical shape resembles a soda can.

A limb with a screwdriver shape is characterized by scar tissue wrapped around the stump. (It looks more like a screw, instead of a screwdriver.) And an edematous shape is characterized by swelling in the residuallimb.

-Pain. Check for general body pain, residuallimb pain and phantom pain. Phantom pain is common and can be problematic. In some cases, you can manage it, and the pain may resolve over time.

Ask the patient to describe the phantom pain. Is it intense burning, cramping or shooting pain? Document pain medications and dosage, since pain issues may play a factor in future prosthetic tolerance.

However, it's important to differentiate between phantom limb pain and sensation. Phantom sensation, which is normal and not painful, is a patient's perception of the presence of an amputated limb. Assess the residuallimb for light and deep touch, temperature and proprioception. Diminished sensation indicates that a patient may have trouble feeling pressure areas.

Note how the patient describes the phantom sensation: increased sensitivity, "feeling" a lost limb, moving lost joints, numbness or tingling.

-Circulation. Check the temperature of a residuallimb and look for hair growth. A warm temperature and hair growth indicates good circulation. With good circulation, breakdown areas or wounds heal faster and easier.

-Scar tissue. Evaluate skin and joint flexibility. Describe the scar tissue's shape, length and location. By documenting these areas early, you can determine potential fitting problems with the interface design/socket. A socket should move with the skin. But a socket that doesn't move freely over rigid scar tissue can cause pressure areas.

-Skin integrity. Look for thin skin, redness, blisters and any areas that could be prone to breakdown from wearing a prosthesis all day.

After you've completed a preprosthetic assessment, form a treatment plan. Preprosthetic treatment is often underused, but it should be thought of as "preparing the limb to tolerate a prosthesis for a full day." Address these areas during the preprosthetic phase of rehabilitation.

-Edema control and residuallimb shaping. This area is important for proper prosthetic fit. Show the patient and family members how to use figure-eight wrapping or apply a compression stockinette/shrinker to reduce edema and shape a residuallimb.

If a limb is wrapped incorrectly or not wrapped, you may not be able to fit a person for a prosthesis. It also will take longer to shrink and shape the limb.

-Desensitization of the residuallimb. The physiological response associated with an acquired amputation may "feel" like the nerves are close to the skin's surface. Nerve endings have certain set end points, typically at the end of fingertips. You have to retrain and reset the residuallimb to new end points.

With desensitization, you can retrain new end points, control pain and build up prosthetic wear tolerance by bombarding a residuallimb with sensory information. Common techniques of desensitization include tapping, vibration, fluidotherapy, massage (light, deep and with different textures), wrapping and weight bearing.

-Pain management. Physicians usually manage pain pharmacologically. However, you can assist this process by applying transcutaneous electrical nerve stimulation to the residuallimb or instructing patients in isometric exercises.

Mirror therapy is another alternative. Ramachandran conducted a study of mirror therapy in unilaterallimb loss patients with phantom limb pain. Patients used a mirror inside a cardboard box to create the illusion that their phantom hand was resurrected. They attempted to send motor commands to both arms, while watching the mirror image that represented the lost arm. Eight out of 10 subjects reported significant improvement with phantom limb pain.

-Scar tissue management. Ultrasound and massage can prevent or reduce scarring and break up scar tissue. This is important for skin flexibility and joint mobility, which gives patients the ability to don and doff a prosthesis and allows more optimal use of the device.

Scar tissue management also decreases the risk of pressure. If tissue doesn't move with the prosthesis, the limb rubs and can cause a blister.

Daily care and inspection help a patient become familiar with his new image and be aware of changes to the residuallimb. Patients should use special lotions with Vitamin A, D, E, lanolin and aloe vera. These lotions moisturize the residuallimb, while toughening and strengthening the skin to tolerate the prosthetic socket. Advise against using regular lotions, since they soften the skin and can increase the chance of skin breakdown.

-Improve/maintain joint ROM. You can handle ROM exercises in the clinic, or teach patients to perform them at home. ROM exercise can be active; passive, with help from another person; or self-administered, with assistance from the other arm, a towel, pulleys or an amputeecuff.

-Increase muscle strength. With periods of inactivity, deconditioning is typical with a traumatic injury. Use cuff weights, elastic bands, a pulley system and amputee cuffs to improve strength in the upper body, back, neck and arms.

Isometric contraction exercises or "flexing" certain muscle groups can tone muscles. These exercises benefit patients who are candidates for a myoelectric arm. In addition, a myotester can strengthen isolated muscles, re-educate them and document signal strength results.

To achieve maximum benefits, people should gradually work up to 20- to 30-minute aerobic sessions, three or four times a week. Exercising every other day helps increase the patient's ability to tolerate a full day of activity without fatigue.

-ADL training. What ADLs are important for complete independence? A patient with unilaterallimb loss can still use the remaining arm/hand and can be independent in most functional tasks. Instruct him in one-handed and compensatory techniques or suggest adaptive equipment, until the prosthesis arrives.

If the patient lost the dominant arm, he'll need to undergo changes in dominance training to relearn basic skills, such as eating, grooming and handwriting. Try not to allow the patient to develop one-handedness. He may view the prosthesis as too difficult and feel he can accomplish tasks faster without the device.

Patients who lose both arms should be admitted to a facility for more extensive training. They'll also be dependent on a full-time caregiver. In these cases, they'll need to use adaptive equipment, such as U-cuffs with pockets for eating and grooming, or learn foot skills to regain independence with basic self-care activities.

A patient should complete preprosthetic treatment before receiving a prosthesis. The timeline always varies, based on healing of skin grafts or wounds, level of amputation, skill and experience of the prosthetist, and insurance considerations. If everything goes according to plan, it's just a matter of time before a patient regains full function and dexterity with an upper extremityprosthesis.

Shawn Swanson, OTR/L, lives in Houston and travels as a clinical specialist in upper extremity prostheses for a prosthetic manufacturer in Minneapolis. Diane Atkins, OTR, FISPO, is a clinical assistant professor in the department of physical medicine and rehabilitation at the Baylor College of Medicine in Houston. Laura Tingleaf, OTR, practiced occupational therapy at Baylor Rehabilitation in Dallas and T.I.R.R. in Houston, and specialized in SCI, TBI, CVA and upper extremity amputations.